because good-quality surveillance and care may reduce long-term costs for all stakeholders. Such efforts at dialogue may facilitate improvements in public health laboratories' attempts to preserve vital elements of their infrastructures.

LEGAL CONCERNS

Presented by René Bowser, J.D.

Fellow, Georgetown University Law Center

Federal and state government responsibility for public health is certainly a necessity but is not a sufficient condition for maximization of public health. Indeed, unilateral actions by governments in fully promoting and protecting the health of the community are limited. For example, governments are not nearly as closely associated with individuals and their health care as managed care organizations are. From this perspective, managed care is better positioned to observe personal choices, obtain information on rates of illness and injury from specific causes, and identify health risks in the community. Furthermore, these organizations generally possess greater expertise in providing cost-effective personal medical services and clinical preventive services than government and are likely to be more flexible in their approaches to solving public health problems. Yet, despite the advantages that managed care organizations bring to public health, few incentives exist for them to provide communitywide public health services.

A deliberative effort should be made to secure managed care's cooperation in expanding public health activities, including surveillance and monitoring. This can be accomplished through well-considered delegations of public health activities, incentives, and regulations. Most local health departments lack the personnel, laboratories, and information systems need to identify and effectively respond to the great variety of health risks facing populations. At the same time, many managed care organizations are developing the capacity to identify clusters of diseases and injuries within the enrolled population and, through investigation, determine their causes. This information is critical for public health policy development and community health assessment. Ideally, surveillance should be a coordinated process in which the health department sets the agenda for surveillance, epidemiological, and statistical studies; contracts with a managed care plan to provide the information; uses the findings to assess health risks; and allocates resources to those events that pose the greatest risks.

Contracting with managed care organizations to identify clusters of diseases in the enrolled population is a desirable strategy. Not only does it identify health risks in the community, but it also provides the managed care plan with information that could serve as the basis for its own prevention strategies to avoid future treatment costs. In addition, managed care can assist in the early detection and control of emerging microbial threats through data collection and analysis. If managed care plans routinely reported the community's health status to offi-



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